FEES versus
MBSS/VFSS
When you have the choice of endoscopy and fluoroscopy to evaluate swallowing, why choose FEES?
How does FEES compare to MBSS/VFSS?
First, what is MBSS/VFSS?
The Modified Barium Swallow Study (MBSS), also called the Video‑Fluoroscopic Swallow Study (VFSS), is a dynamic X‑ray examination of swallowing. Performed in a hospital radiology suite by a multidisciplinary team—Radiologist, Radiology Technologist, and Speech‑Language Pathologist (i.e. Speech Therapist or "SLP")—it involves:
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Preparation: Patient seated upright (bedbound or Hoyer/Broda patients often cannot participate)
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Procedure: Ingestion of barium‑coated foods and liquids under continuous fluoroscopy
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Limitations: Time‑limited (to minimize radiation), simulated consistencies, and no assessment of fatigue
How does this compare to FEES?
FEES and MBSS/VFSS are similar in many ways, but there are some distinct differences.
1. Wait Times: Due to MBSS/VFSS typically being completed in a video-fluoroscopy suite (i.e. x-ray suite) at a hospital, wait times for completing the assessment are long. Typically, it takes at least 3-4 weeks, if not longer, for a MBSS/VFSS to be completed, and that is not considering possible transportation issues or cancellations due to staffing. Comparatively, completing an assessment with FEES is quick. E's Mobile FEES typically completes a swallow study and sends over the evaluation report within 24-72 hours, compared to the few weeks it takes with MBSS/VFSS. This often equates to substantial cost savings for facilities.
2. Team Size: While MBSS/VFSS are completed with a team including the Radiologist, Radiology Technologist, and SLP, FEES is completed by only one person (no team involved). That person is a Speech-Language Pathologist with specialized training in endoscopy, making FEES less expensive to complete.
3. Transportation: Because MBSS/VFSS is completed in a video-fluoroscopy suite (i.e. x-ray suite), the patient must be transported there. If the facility has a vehicle or the family is able to transport, this isn't a problem, but, oftentimes, this isn't the case. Transportation typically needs to be organized, which can be expensive, difficult to coordinate, and is often hard on / exhausting for medically fragile or medically compromised patients. With FEES, there are no transportation issues or transportation costs because FEES comes directly to the facility and completes assessments in-house. FEES can be done when a patient is in bed, in a wheelchair or recliner, or in a space they find most comfortable, which makes the whole process easier and most simplistic for everyone involved.
4. Mobility & Patient Limitations: MBSS/VFSS can be limited by a patient's mobility and body shape/size. This is because of the set-up needed in the video-fluoroscopy suite (i.e. x-ray suite) where MBSS/VFSS are completed. Patients need to be seated upright with the x-ray arm surrounding them. Many patients who are bedbound, who utilize a Hoyer for mobility, or who utilize a Broda Chair for sitting, cannot participate in a MBSS/VFSS or have substantial difficulty completing a MBSS/VFSS simply due to the set-up needed to complete one. Alternatively, FEES meets the patient where they're at, whether that's in bed, in a Broda Chair, in a wheelchair, or anywhere else they find comfortable. The patient doesn't have to be upright for a FEES either- they can be in the position they typically eat and drink in, so we can simulate the most realistic swallowing experience.
5. Environment: Especially for patients with cognitive impairments, where they're located when assessing the swallow is important. Maybe they simply wouldn't be able to participate in a MBSS/VFSS because they would be confused or behavioral or maybe they typically eat in a crowded Dining Room with a lot of distractions, so the set-up of a MBSS/VFSS wouldn't be appropriate. The goal of FEES is to simulate how a person typically eats and drinks, wherever that is and whoever that is with. Oftentimes, especially for patients with cognitive impairments, FEES is easier and safer to complete because it can be completed in a familiar environment with people they trust. Additionally, rapport can often be built between the patient and SLP completing the FEES more easily because there are no time limitations and the patient is more comfortable to begin with.
Are there differences in quality between the two? Is one swallowing assessment considered better than the other?
No, there are no differences in the quality of swallowing assessment between FEES and MBSS/VFSS. Current clinical research supports that both FEES and MBSS/VFSS are their own “gold-standards.”
What assessment is recommended really comes down to what information is needed, where the patient is located, and if the patient can be transported. In some situations, both FEES and MBSS/VFSS may be necessary to completely understand the complexity of the swallowing disorder.
Though both can be considered "gold-standards," FEES has repeatedly demonstrated a sensitivity equal to or greater than MBSS/VFSS in determining whether a patient is exhibiting penetration, aspiration, delay in swallowing initiation, and pharyngeal residue. Additionally, FEES provides visualizations of pharyngeal secretions (i.e. throat secretions) that cannot be detected during MBSS/VFSS.
Learn more about FEES and MBSS/VFSS research and articles HERE
Now, why choose FEES?
See some examples below:
Your patient has positioning limitations or doesn't tolerate leaving the facility or room (bedbound, Broda Chair, etc.):
FEES is completed at the patient's bedside, chair/wheelchair, dining room, lounge, or wherever they feel most comfortable. If the patient cannot sit upright, FEES is completed in the position that the patient will be in during eating.
There are no positioning limitations when conducting FEES.
Since FEES doesn't require transport and the patient can be in any comfortable position for testing, the patient is kept comfortable throughout the duration of the assessment, no matter the time length. FEES allows for a patient to eat and drink at their own pace, so their actual day-to-day eating and drinking is assessed.
Example patients include: Bariatric patients, bedbound patients, patients with wounds, patients who are ventilator dependent, patients who are easily fatigued, and patients with CP, MS, or MG
Your patient has severe pharyngeal dysphagia and you're concerned about aspiration during testing:
Aspiration of secretions or aspiration of enteral feeds are major predictors for possible development of aspiration pneumonia. FEES is a sensitive and conservative assessment that aids in the visualization of secretions, possible enteral feed backflow, and intake of ice chips because of its ability to visualize the throat and swallow in full color.
With FEES, there is no need to delay testing for patients who have severe to profound dysphagia. Critical information can be obtained at the bedside regarding specific swallowing impairments and anatomical integrity. This allows for appropriate therapy plans and recommendations to be established right away.
Example patients include: Patients who are feeding tube dependent, patients who are NPO, patients who are at risk for silent aspiration, patients who have progressive neurodegenerative conditions, and patients who have an increased risk for impaired cough reflex
Your patient has respiratory difficulties that impacts their swallow:
The prevalence of dysphagia in those with COPD and other pulmonary disorders is high. Research indicates that patients with COPD have a high tendency for aspiration and have reduced laryngeal sensation (i.e. throat sensation). One, or both, of these can lead aspiration and silent aspiration. Furthermore, patients with pulmonary deficits frequently cough outside of oral intake, making it difficult to determine if dysphagia is present and if it is impacting generalized swallowing safety.
FEES offers a direct view of the swallow and respiratory pattern as both the airway and pharyngeal swallow can be seen during the assessment. Disruptions in breath/swallow coordination, as well as the impact of shortness of breath, can be assessed during FEES.
Example patients include: Patients with COPD and other pulmonary deficits, patients with tracheostomy, patients who are ventilator dependent, and patients who may have reduced respiratory capacity or respiratory fatigue
Your patient would benefit from assessment with real foods and liquids, or they have specific food/liquid preferences:
The sensory properties of foods and liquids are well known to impact swallowing function. Taste, texture, and temperature all impact a patient's swallowing safety. In addition, some patients may not like the taste or texture of barium or may be allergic to it, which can limit the results of a MBSS/VFSS.
Any of these challenges need to be considerations when deciding between FEES and MBSS/VFSS for accurate instrumental evaluation of swallowing. During FEES, real foods and liquids are utilized and specific food items that have been problematic for or preferred by a patient can be tested specifically.
Example patients include: Patients with dementia, patients who are cognitively impaired, patients who have sensory needs, patients who have progressive neurodegenerative conditions/diseases, and patients who have had a stroke
Your patient has reflux or other G.I. issues:
Frequent throat clearing, patient report of a globus sensation or feeling that something is stuck or sticking, and frequent belching, vomiting, or regurgitation of foods/liquids can all have an impact on swallowing.
During FEES, evidence of reflux in the pharynx and larynx (i.e. throat) can be graded using a reflux finding scale. Tissues are viewed directly and findings of swelling, redness/discoloration, mucus, and other anatomical changes are assessed and noted. Regurgitation or backflow can also be viewed as it returns from the upper esophageal sphincter into the pharynx (i.e. returns from the stomach tube into the throat).
From here, if findings consistent with esophageal dysphagia or reflux are present, appropriate recommendations can be made. FEES can be an excellent first step in aiding the clinical management of reflux and its associated symptoms.
It is a misconception that MBSS effectively evaluates the esophageal stage of swallowing. G.I. consult is the appropriate follow-up when esophageal dysphagia is suspected or identified.
You're concerned about the anatomical integrity of your patient's swallowing structures or structural changes are noted in your patient's medical history:
Clinicians who have access to FEES have the advantage of being able to view the patient's generalized vocal cord function, anatomical structures, and presence of obstructing anatomy that may impact functional swallowing (such as swelling or lesions).
FEES can also be used to visualize secretion management, the quality of the patient's oral care and/or suction routine, and can determine if there is possible anatomical pathology that warrants further medical management or follow-up.
Example patients include: Patients with dysphonia or vocal fold paralysis, patients with a history of intubation or throat surgery, patients with a history of radiation, patients who have a tracheostomy, patients who have a nasogastric feeding tube, patients who have GERD or LPR, patients at risk for developing aspiration pneumonia, and patients who have complaints of a globus sensation